The College has seen a significant increase in complaints alleging sexual misconduct, in particular, where a physical therapist moved a client’s undergarments, or touched breast tissue. This is a troubling trend. When the physical therapist was made aware of the complaint, they were often shocked to hear how the client experienced the interaction. While the overall number of complaints remains small, any increase in allegations of sexual misconduct warrants our attention. We need to consider what can be done to change the client experience so that they feel safe.
To be clear, sexual misconduct is an egregious offence and the College deals with it accordingly. However, the complaints often paint a picture that suggests the intent of the physical therapist was to provide hands on assessment or treatment, but the impact is that the client experienced something different. We can do more in these scenarios to ensure that clients understand our therapeutic intent by using clear communication and by seeking more specific permissions. College Practice Standards on Consent (#7) and Professional Boundaries & Sexual Misconduct (#14) outline our obligations to our clients.
What we hear from the patient (client) when they make a sexual misconduct complaint:
- During the course of treatment, the physical therapist:
- moved a client’s bra/underwear, or moved/unclasped a client’s bra, without having informed them that moving/unclasping their undergarment would be necessary
- touched, cupped, squeezed a client’s breast tissue (either under or on top of their garments)
- The physical therapist did not seek their permission and as a result they felt shocked and perceived the event as inappropriate and sexual in nature.
- The client reported feeling frozen with fear and perceived the event as a sexual violation/assault.
- They did not raise their concerns with their physical therapist because they were unsure of what was happening at the time; and/or they were afraid of confrontation in case it escalated the conduct.
What we hear from the physical therapist in response to the complaint:
- They believed that consent to move/unclasp the undergarment was implied because the client had consented to treatment in the area and that moving/unclasping the undergarment was necessary to provide such treatment.
- They were treating conditions related to the corresponding muscle group near the breast and obtained the client’s general consent to treatment.
- That they considered the touch to be therapeutic and the client misperceived the treatment.
In a profession that involves being in close physical proximity, clearly visualizing the area we are treating, and putting hands on bare skin (often in areas that are usually covered by clothing), we must remain sensitive to how our clients are experiencing the interaction. While we are busy focusing on assessing, treating and problem solving are we inadvertently overlooking the fact that the client is unclear, uneasy, or uncomfortable?
Clients typically don’t speak up to express their concern or discomfort to their physical therapist. Instead, they leave and don’t return, and they reflect on an experience that felt sexually inappropriate. Many complainants reported asking family, friends, and other health care professionals if the treatment was appropriate prior to submitting a complaint to the College. Some clients also file a report with the RCMP / police leading to criminal charges. These complaints regularly come as a complete surprise to the registrant who had no indication that the client perceived the treatment as sexual misconduct.
How do we improve the client experience?
Clients expect us to seek specific permission, in plain language, when undergarments will be moved or where breast tissue might be touched. Specifically, they expect us to let them know that to assess their low back we’d like to move the band of their underwear, to assess their shoulder we’ll need to move their bra strap aside, or that to feel how their ribs are moving we’ll place our hands here (demonstrate on yourself). Then, and this is important, we need to ask them if that is okay before proceeding. If they consent, we could ask the client if they would prefer to move the underwear/bra strap themselves.
If a physical therapist inadvertently brushes a client’s breast during treatment, they should consider apologizing and asking if it is okay to proceed. Clients report that if the incident is not acknowledged it leaves them to come to their own conclusions about the physical therapist’s intent.
The message we are hearing from the public is loud and clear: in the context of physical therapy assessment or treatment it’s not enough to seek consent to treat a client’s low back or shoulder girdle when underwear or bra straps need to be repositioned, or where contact may be made with breast tissue, best practice is to seek specific permission from our clients. Simply seeking this permission can make all of the difference in how comfortable clients feel during physical therapy. That’s a message worth hearing.